A Warning Sign on the Road to DSM-V: Beware of Its Unintended Consequences
By Allen Frances, MD
June 26, 2009
…The DSM-V goal to effect a “paradigm shift” in psychiatric diagnosis is absurdly premature. Simply stated, descriptive psychiatric diagnosis does not now need and cannot support a paradigm shift. There can be no dramatic improvements in psychiatric diagnosis until we make a fundamental leap in our understanding of what causes mental disorders. The incredible recent advances in neuroscience, molecular biology, and brain imaging that have taught us so much about normal brain functioning are still not relevant to the clinical practicalities of everyday psychiatric diagnosis. The clearest evidence supporting this disappointing fact is that not even 1 biological test is ready for inclusion in the criteria sets for DSM-V…
So long as psychiatric diagnosis is stuck at its current descriptive level, there is little to be gained and much to be lost in frequently and arbitrarily changing the system. Descriptive diagnosis should remain fairly stable until, disorder by disorder, we gradually attain a more fundamental and explanatory understanding of causality. Indeed, there has been only 1 paradigm shift in psychiatric diagnosis in the past 100 years—the DSM-III introduction in 1980 of operational criteria sets and the multiaxial system. With these methodological advances, DSM-III rescued psychiatric diagnosis from unreliability and the oblivion of irrelevancy. In the subsequent evolution of descriptive diagnosis, DSM-III-R and DSM-IV were really no more than footnotes to DSM-III and, at best, DSM-V could only hope to join them in making a modest contribution. Descriptive diagnosis is simply not equipped to carry us much further than it already has. The real paradigm shift will require an increase in our knowledge—not just a “rearrangement of the furniture” of the various descriptive possibilities.Part of the exaggerated claim of a paradigm shift in DSM-V is based on the suggestion that it will be introducing dimensional ratings and that this will increase the precision of diagnosis. I am a big fan of dimensional diagnosis and wrote a paper promoting its use as early as 1982. Naturally, I had hoped to expand the role of dimensional diagnosis in DSM-IV but came to realize that busy clinicians do not have the time, training, or inclination to use dimensional ratings. Indeed, the dimensional components already built into the DSM system (ie, severity ratings of mild, moderate, and severe for every disorder and the Axis V Global Assessment of Functioning scale) are very often ignored. Including an ad hoc, untested, and complex dimensional system in an official nomenclature is premature and will likely lead to similar neglect and confusion…
Setting the Record Straight: A Response to Frances Commentary on DSM-V
By Alan F. Schatzberg, James H. Scully Jr, David J. Kupfer, Darrel A. Regier
July 1, 2009
Dr Schatzberg is President of the American Psychiatric Association.
Dr Scully is Medical Director, CEO, of the American Psychiatric Association.
Dr Kupfer is Chair, DSM-V Task Force
Dr Regier is Vice Chair, DSM-V Task Force…The DSM-III categorical diagnoses with operational criteria were a major advance for our field, but they are now holding us back because the system has not kept up with current thinking. Clinicians complain that the current DSM-IV system poorly reflects the clinical realities of their patients. Researchers are skeptical that the existing DSM categories represent a valid basis for scientific investigations, and accumulating evidence supports this skepticism. Science has advanced, treatments have advanced, and clinical practice has advanced since Dr. Frances’ work on DSM-IV. The DSM will become irrelevant if it does not change to reflect these advances.
Finally, Dr. Frances opened his commentary with the statement, “We should begin with full disclosure.” It is unfortunate that Dr. Frances failed to take this statement to heart when he did not disclose his continued financial interests in several publications based on DSM-IV. Only with this information could the reader make a full assessment of his critiques of a new and different DSM-V. Both Dr. Frances and Dr. Spitzer have more than a personal “pride of authorship” interest in preserving the DSM-IV and its related case book and study products. Both continue to receive royalties on DSM-IV associated products. The fact that Dr. Frances was informed at the APA Annual Meeting last month that subsequent editions of his DSM-IV associated products would cease when the new edition is finalized, should be considered when evaluating his critique and its timing.
Both of the two main topics from Dr. Frances’ initial criticism above – the paradigm shift to a biological basis for the DSM-5 and their complex dimensional system – were totally abandoned along the way [for the reasons he foretold]. In addition, also along the way, the APA DSM-5 Task Force has managed to alienate almost every one of the non-medical mental health professions by looking at mental illness through the monocular lens of a subset of psychiatrist neuroscientists.
While I obviously agree with Dr. Frances’ perspective and did when he first started talking about it in 2009, the thing about the road behind that bothers me is not just their inappropriate insertion of the biological agenda into the DSM-5 revision, it’s what they didn’t do. As I’ve gone through the Clinical Trial literature over the last twenty-five years, it’s abundantly clear that the imprecision of the DSM-III+ has made a mess of the drug trials that underlie our psychopharmacology literature, particularly in depression. In practice, the majority of antidepressant prescriptions are written based simply on a patient’s report, "I’m depressed," not on a careful evaluation. Worse, even in situations where a patient is thoroughly examined, the existing category of Major Depressive Disorder is so broad and overly-inclusive that the best cohort possible is still unacceptably heterogeneous.
In adults, it includes Melancholic Depression, the depressive affect of people with personality disorders, situational depressions, the culturally deprived, the traumatized, etc. etc. In kids, it’s worse. I’ve never personally seen a depressed adolescent that didn’t have an apparent reason to be depressed – and it’s usually a reason that needed to be addressed. We all know that Major Depressive Disorder was a political creation [as historian Ed Shorter puts it], and yet nobody took it on as an area in need of the intense study it deserves. I sure don’t blame just psychiatry for the depression problem, though we certainly have played our role. Both the third party carriers [insurance] and the pharmaceutical industry have a major part in the depression game – both driven by money, not mental health. But it’s ours to fix, and I don’t even think the DSM-5 Task Force looked at it. They kvetch about the problem of not being able to map their drugs or their neuroscience findings on clinical diagnoses, but matching anything with that category is like matching long words with a bowl of soggy alphabet soup. That’s the loudest example, but there are many others.